Evaluation of the habits of exposure to the sun and guidance on photoprotective measures in transplanted young adults: a cross sectional study

Received on: 08/05/2018

Approved on: 24/09/2018

This study was performed at the Dermatology Service, Santa Casa de Porto Alegre - Porto Alegre (RS), Brazil.

Financial support: None

Conflict of interests: None

Abstract

INTRODUCTION: Skin cancer is the most frequent tumor in transplanted patients. Evaluating how transplanted young adults behave regarding the exposure to the sun is an important step in introducing prevention programs in this population.
OBJECTIVE: To evaluate the photoprotection habits of transplanted young patients and to determine whether the guidance on the use of sunscreen increases the use of photoprotection measures.
METHODS: Cross-sectional study. A questionnaire was applied at the post-transplant post-adolescents clinic.
RESULTS: Forty-nine patients were interviewed (mean age = 22.9 years, SD = 4.6 years). The rate of use of sunscreen was 40% among those who had not been instructed and 93.2% among those who had been instructed. There was a statistically significant association between having been instructed on the use of and using sunscreen (p = 0.01). Most patients reported having used sunscreen. Limitations of the study: the interviewees’ level of schooling was not evaluated.
CONCLUSIONS: Young transplanted patients who are instructed during the consultations to use sunscreen adhered more to the application of sunscreen than patients who had not been instructed. It is of utmost importance to educate transplanted young adults about skin cancer prevention whenever possible, preferably at each visit.

Keywords: Kidney transplantation; Organ transplantation; Skin neoplasms; Skin care; Sunscreening agents; Young adult

INTRODUCTION

Increased survival of transplanted patients over the years has contributed to skin cancer becoming a major cause of morbidity in this group, alongside infections, chronic rejection, and cardiovascular complications.^1,2 Skin cancer accounts for 37% to 50% of all neoplasms in transplanted patients. A 20-year follow-up study has shown that between 40% and 50% of recipients in Western countries and between 70% and 80% of Australian transplant recipients have developed at least one non-melanoma skin cancer throughout their lives.^3-6 The impact of immunosuppressive therapy on the development of skin cancer is widely known, however poorly defined, since dermatologic factors (phototype and exposure to ultraviolet radiation), and genetic factors (such as polymorphisms in the p53 tumor suppressor gene) are important interveners, and it is difficult to quantify the real role of each of these.^7-11 Transplanted patients may experience increases of between 65 and 250 times in the number of squamous cell carcinomas (SCC),^4,5,12-14 increases of between 10 and 16 times in the number of basal cell carcinomas (BCC),^4,5 an increase from 3 to 8 times in the number of melanomas,^15-20 (although the number of reported cases is small)^12,21, and an increase of 84 times in the number of Kaposi sarcomas (KS).^22-24 Similarly to what occurs in the general population, the rate of incidence varies directly with the exposure to the sunlight, with linear increase in the occurrence of skin cancer over time.^25,26 A population in which preventive education is of particularly importance, is that of transplanted patients. Some studies involving education on skin cancer demonstrate increased knowledge regarding prevention; nevertheless with little or no effect on improved protection against sunlight.^27-29 Transplanted patients should receive education about protection against sunlight, including on how to avoid exposure, wear adequate clothes and make appropriate use of sunscreen. Tanning should be ruled out.³⁰ Despite the fact that it is recommended to use a broad-spectrum sunscreen, this often leads to the use of a lower amount than necessary due to the characteristic thick texture of the products.³¹ Studies show that less than half of the patients receive specific education for skin cancer.³² Education should be renewed at regular intervals – preferably at each visit – aimed at keeping its effectiveness.

Evaluating how our population of transplanted patients behaves regarding exposure to the sunlight is an important step for introducing a targeted prevention program. The aim of the present study is to evaluate the photoprotection habits of young adult patients who undergo treatment and follow-up after renal transplantation at the Santa Casa de Misericórdia, Porto Alegre, RS, Brazil. The specific objective is to determine whether guidance on the use of sunscreen increases the regular use of photoprotection methods.

METHODS

A cross-sectional study was conducted between May 05 and August 05 in 2015. A questionnaire was administered during the visits to the post-transplant outpatient clinic of the Santa Clara Hospital of the Complexo Hospitalar Santa Casa de Misericórdia de Porto Alegre, during the study period. The patients signed the Free and Informed Consent Term. Of the 56 patients who attended medical visits during this period, 49 accepted to participate in the study. The data were entered on an Excel software spreadsheet and then exported to a statistical analysis software. Categorical variables were described by frequencies, while percentage and quantitative variables were described using mean values and standard deviations. The existence of associations between the variables was verified using the chi-square test. A significance level of 5% was considered. The project was approved by the Institution’s Ethics Committee (number 27119414.0.0000.5335), and the study complied with the Declaration of Helsinki. At the end of the interview, patients were provided with guidance material on the importance of photoprotection, especially in transplanted patients.

RESULTS

Of the 56 patients seen during the study period, 49 were interviewed. The main data regarding the study population are shown in Table 1.

The majority of patients reported having been instructed regarding photoprotection (Graph 1), with the nephrologist physician as the main source of advise (Table 2).

Twenty interviewees (40.8%) revealed to be unaware of the reason why transplanted patients require more photoprotection. Of the 6 patients who reported not making use of sunscreen, half alleged to ignore the necessity of doing it, while the remaining ones did not use it for cosmetic reasons. The use of sunscreen was 40% among those who had not been instructed and 93.2% among those who had been educated (Table 3). There was a statistically significant association between to be educated on the use of sunscreen and to use sunscreen (P = 0. 01).

DISCUSSION

The interviewed group consisted of adults in their 30’s, mostly Caucasians, who underwent transplantation at an early age (with foreknowledge of long-term use of immunosuppressive drugs), meaning a higher risk of development of skin cancer. More than half of these patients are aware of their increased risk of skin cancer, which is in line with the results of a 2005 study in Poland with renal transplant recipients.³³ It has been observed that almost all use some form of photoprotection. There was higher adhesion to the use of sunscreen among patients who were instructed to do so as compared to patients who did not receive this information, with a statistically significant difference (P <0.003). This differs from two studies carried out in schools,^28,29, which demonstrated that education increased the knowledge about prevention of skin cancer, but did not modify the behavior of younger people. The majority of patients were instructed on how to carry out photoprotection, which is in line with the literature.^32,33 It was observed that half of the cases of non-use of sunscreen were due to lack of information on the necessity to do so. The nephrology team plays an important role, having been responsible for educating the majority of the interviewees. Only a few patients reported never having received information on this subject.

CONCLUSION

Transplanted patients at an early age remain for longer time under immunosuppressive therapy and normally have less exposure to the sunlight, meaning this is a group of special importance for education on the prevention of skin cancer. This public should therefore be advised on the need for photoprotection whenever possible, preferably at each medical visit.

DECLARATION OF PARTICIPATION:

Mauricio de Quadros | ORCID 0000-0003-1824-1729
Análise estatística, aprovação da versão final do original, concepção e planejamento do estudo, elaboração e redação do original, obtenção, análise e interpretação dos dados, participação efetiva na orientação da pesquisa, participação intelectual em conduta propedêutica e/ou terapêutica de casos estudados, revisão crítica da literatura, revisão crítica do original

Bianca Coelho Furtado | ORCID 0000-0002-2202-9627
Aprovação da versão final do original, concepção e planejamento do estudo, elaboração e redação do original, obtenção, análise e interpretação dos dados, participação efetiva na orientação da pesquisa, participação intelectual em conduta propedêutica e/ou terapêutica de casos estudados, revisão crítica da literatura, revisão crítica do original

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